Category: Crossfit

As promised, this is part 2 of my series on pelvic floor problems in the adult athlete. Part 1 discussed pelvic floor pain- what it is, how it happens, and how it is treated. If you missed it, you can still check it out here. Today, we will cover stress urinary incontinence in athletes.

Guess what? Leaking is not normal. Ever. Never. Nope.

At some point over the years, women became convinced that after having children it suddenly becomes normal to leak urine when coughing or sneezing. Or, that if you work out really really hard, or jump rope really quick, or jump on a trampoline, it’s normal to pee a little bit. But guess what? It’s not. And I firmly believe that no woman (or man!) should have to “just deal with it.”

Bladder problems during exercise are very common– Here are some stats:

This summary article estimated that 47 % of women who regularly engage in exercise report some degree of urinary incontinence. (Other articles have shown big variety, with one review stating the prevalence varies from 10-55%)

This study found that in 105 female volleyball players, 65% had at least one symptom of stress urinary incontinence and/or urgency.

In elite athletes (including dancers), this study found a prevalence of urinary problems at 52%.

Summary: Urine loss during exercise is COMMON. And it’s about time we do something about it!

So, what is stress urinary incontinence (SUI)? Basically, SUI is involuntary leakage of urine associated with an increase in intra-abdominal pressure. For those who exercise regularly, this can occur with running, jumping (jumping rope, jumping jacks, box jumps, trampoline), dancing (zumba, too!), weight lifting, squatting, pilates/yoga, bootcamp classes, kicking, and many other forms of exercise.

**Note: Although SUI is one of the most common forms of urinary dysfunction we see in athletes, other problems can exist as well. This can include stronger urinary urgency, frequency (going too often), and/or difficulties emptying the bladder or starting the stream. Bowel dysfunction is also a problem with many athletes, and can include bowel leakage, constipation, or difficulty emptying the bowels.

Why does it happen? There are many causes of bladder leakage, so it is always important to be medically evaluated. We know that hormones can play a role, as well as anatomical factors (pelvic organ prolapse or urethral hypermobility). Other factors can include childbirth history, body mechanics, breathing patterns/dysfunction, obesity–and I’ll add here, previous orthopedic injury or low back/pelvic girdle pain.

From a musculoskeletal viewpoint, SUI has to do with a failure of the body to control intra-abdominal pressure. Basically, there are forces through the abdomen and pelvis during movements, and our body has to control and disperse those forces. The deepest layer of muscles that work together for pressure modulation are the pelvic floor muscles, the transverse abdominis, the multifidus, and the diaphragm. In terms of the pelvic floor muscles specifically, remember that we want strong, flexible, well-timed muscles. Tight irritated muscles can contribute to UI just as much as weak overly stretched out muscles. We have discussed this many many times on this blog, but if you’d like a review of that, read this piece on why kegels are not always appropriate for UI and check out the videos by my colleague, Julie Wiebe, posted there. It is also important that a person has properly firing muscles around the pelvis–especially the glutes! but also the other muscles around the pelvis that help to move you.

The way in which a person moves can also be a significant contributing factor to SUI. For example, if a person holds his or her breath during jump rope, the diaphragm is not able to move well and the entire pressure system will be impacted (leading to possible leaks!). I have also seen women develop SUI or pelvic organ prolapse after performing regular exercise using incorrect form/alignment or after performing exercises that were too difficult for them to do correctly. Often times, this leads to compensatory strategies that can make pressure modulation very difficult for the body.

What can you do about it? First things first–stop “just dealing with it!” I recommend a medical evaluation to start, but always encourage people to seek conservative treatments first prior to medications and/or surgery. The best person to evaluate you from a musculoskeletal perspective is a PT who is specialized in treating pelvic floor dysfunction (and if you live in metro Atlanta and have SUI, come and see me!). The physical therapist will do a comprehensive evaluation which will include:

Head to toe evaluation of your spine, ribcage, abdominal wall, hips, breathing patterns, alignment/posture, knees…all the way down to your feet to see how your movement at each spot could be influencing your pressure system. We also look at how your various muscles fire to help to identify which muscles may not be firing at the right times or which muscles may be tight and impacting your movements.

Evaluation of the pelvic floor muscles. As the pelvic floor muscles are located internally, the best way to assess them is with an internal vaginal or rectal assessment. That being said, if you are uncomfortable with that, there are options for external assessment that will help the PT gather some information (just know that this will likely be less thorough).

Treatment for SUI often includes:

Re-establishing the proper timing and coordination of the pelvic floor, diaphragm, multifidus and transverse abdominis to stabilize the lumbopelvic region and modulate pressure during movements. Remember, our goal is to optimize this team working together–it’s not just about the pelvic floor, and kegels are not always the answer.

Retraining the proper firing of the muscles around the pelvis during movements.

Correction of postural/alignment problems which could be contributing factors

I love the changes I’ve seen in our culture over the past 10 or so years. Healthy foods? Regular exercise? Joining gyms, boxes, studios, programs? This has become the norm for many people—and, that is so awesome! I love to see people being more active, taking responsibility for their health, and really striving to care for their bodies throughout their lifespans.

However, with this change and shift toward more activity, I have started seeing some pelvic problems become more common. And I don’t blame the exercise—I really don’t! I will stand firm in my belief that there is no such thing as a bad exercise—but all exercises require proper form and performance. Sometimes when we consistently perform exercises that we may not be able to do correctly, problems can creep in. I don’t see this to scare anyone off from exercises– please don’t think I mean that! But I think it is important to remember that Pain is never normal. Bladder leakage? Bowel problems? Sexual pain? Also never normal.

So, the next two posts are going to address two of the major things I am treating regularly in higher level athletes. Today we are going to talk about Pelvic floor muscle pain, and next week I will post about stress incontinence. Let’s get started.

Pelvic floor muscle-related pain

What is it? This problem occurs when the muscle of the pelvic floor become tender, overactive or hypervigilant(basically contracting with too much intensity to guard/protect the pelvis) Often when this happens, people will feel pain in the lower abdomen, groin, hip, buttock or low back—or may feel actual vaginal/rectal pain. The pain may also be associated with changes in bladder function (like increased urinary frequency, urgency or leakage), bowel function (like constipation or difficulty emptying bowels) or sexual function (typically pain or discomfort during intercourse.) However, sometimes people will experience pain without any of these other symptoms at all.

Why does this happen? This is the kicker–We don’t always know exactly why. However, there are some common reasons why the pelvic floor muscles might begin responding this way. First, we have to remember that the pelvic floor is just one part of a team of muscles that work together to modulate pressure within the abdomen and pelvis. So, the diaphragm, transverse abdominis, multifidus and pelvic floor work together to control intra-abdominal pressure, and pre-activate to support the spine and pelvis during movement.

Dysfunction in any one of these muscles can lead to problems with others. For example, I often find tender, irritated muscles in women after childbirth, especially those who have a diastasis rectus (separation at midline between the two rectus abdominis muscles). This separation impacts the stability at the abdominal wall, generally leading to gripping of the internal and external oblique muscles, alterations in ability to breathe optimally, and thus gripping at the pelvic floor muscles. We see a similar pattern occur in men and women with hypermobility. We can also see dysfunction creep in as a motor adaptation when someone has a history of low back, hip, neck, knee or other musculoskeletal problems.

In terms of athletes in particular (and yes, this includes those of you doing Crossfit, Barre, personal training, yoga, pilates, and other regular exercise— YOU are an athlete J), I often find that when a person lacks dynamic stability, the pelvic floor will compensate to give that stability. If a person is then doing regular exercise and does not have the adequate control, form, or force modulation to perform, these compensations become more prevalent and can then lead to pain.

What can you do about it? If you think your pelvic floor may be a contributor to pain, the first step is to seek evaluation. It can be helpful to initially seek a medical evaluation to rule out other potential pain contributors (ovarian cysts, inguinal hernias, etc.). Then, I do strongly recommend seeking an evaluation by a skilled physical therapist with advanced training in pelvic health. If you are living in a state that allows self-referral to physical therapy (like Georgia!), you can see a physical therapist without a physician referral; however, if in doubt, check with your local physical therapy office.

Treatment for pelvic floor related pain in athletes typically focuses initially on re-establishing the optimal function of the pelvic floor muscles within the team of muscles we spoke about earlier. This is done by teaching the patient how to relax the pelvic floor muscles, use the amazing diaphragm in the proper coordination with the pelvic floor and abdominals, and often includes manual therapy to help reduce muscle tenderness and/or improve connective tissue or neural mobility around the pelvis. A skilled pelvic floor PT will not only assess the pelvic floor muscles, but will examine you from a whole-body perspective—watching you move in various motions, looking at your hips/back/knees/ankles and assessing the soft tissues that could be contributors to your symptoms. This allows us to not only identify which tissues are contributing to the pain you experience, but also to identify any abnormal movement patterns which could be leading to the compensation in the first place.

Once the pelvic floor muscles are no longer hypervigilant/tender/overactive, we focus on restoring healthy movement. This includes integrating the pelvic floor and its team within those movements—the right way! Typically at this point, we progress the athlete to his or her specific movements—whether that is Olympic lifting, squats, or a yoga warrior series—teaching the athlete proper form all while integrating the right muscle firing patterns to adequately stabilize.

Do I have to stop exercising while in PT? This is always a tough one. I totally recognize that many adult athletes love their work-out routines and benefit so much by them—physically, socially, and emotionally. Sometimes there will be particular exercises that are aggravating symptoms or worsening the problems the person is experiencing. In those cases, I often will recommend holding off on those movements for a short time period. While holding off on some exercises, we often can still work together to find exercises and movements that are appropriate and totally acceptable to keep performing! I know this period can be frustrating for patients as it is difficult to take a break from something you love, but I promise, it’s short! Our goal ultimately is to get people back to the activities they love as quickly and safely as we can!

If you are having pelvic pain during exercise, and you live in the Atlanta area, I would LOVE to see you! Feel free to contact me or call my office for more information!

I always love to hear from you! Please let me know if you have any questions or feel free to chime in if I left something out! Happy Thursday!